21632 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification IS yFd e.G C D 1� PERMIT NO.
1 �a''S�n/
BuBding Address: T LJ 1 V fJ
o Z_ ask-p ad C�1 a (e -r MJS c
wners time: one: p
CL'-��- ' CITY OF CUPERTINO-BUILDING DIVISION
C o shame: `—J ot�j �$Lir.No: APPLICATION /PERMIT
1 J TCJ CATEGORY CONTROL N
ArcARect/Engineer. Lk No: BUILDINGELECTRICA4PLUMBINC-MFL NICAL
QTY ELECTRIC PERMIT FEE A- ,BUILDING PERMIT INFO
ddms PERMITISSUANCE 8 �1L ❑ ❑
LICENSED CONTRACTORS DECLARATION I/
I hercedion7Olhatlamticensed.i.3.fthunder provisions nd Pmf ft pmar9(mmmrnc APPLIANCESREADENTIAL JOB DFSCRIPI'ION
Ingwe i,in fon7000)of Division 3.fthe Businesand Profesgons Cade,and my
Emnae tamrou���_roroearyryryryl111erreet. s PANELS
Dan— ss C _Cortr. 1 Q S
Date_ •{� /—CHITEor !S"I`I 281-1WBAMPS ` J
ARCHITECTS DECLARATION OVEAIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
µQ!O7O Iundentand s 86e—used�blic�rc—m�r,ds_ l
L%UE Limned Prof ..If 1y/✓" SIGNSELECTRICAL 0
Q uI OWNER-BULDER DECLARATION
to F' SPECIAL CQ2CUIT/M15C
a., (hereby a(Orthat(tins exempt nt
from Contractor's License law(or the
ZO pGp m following reason.(Section 7031.5,Business and Professions Code:Any city or gyp,ME For, ST.
F .F~j countywhichmquimsaper ttocomtmdalteglmprov demolkh,orrcpair
Y4Y anystructure pdortolts issuance,alsorequires theapplicant for suchpext1.
C file a signed stateroom stateent that he V licensed pursuant to the provisions of the POWER D
OwG
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWENMINC L
[5 gon3ofthe Busi con dProfesslo®Code)orthathebexemM therefmmand VALUATION
the basis for the alleged exemption. Any violation of t 7031.5 by any OUTLETSSWITCFfF_SFUCFUR
666 appliessubjectsapplicant permit the applicant tea civil penalty.(not more than
w five hundred dollars($500). NEW RESIDENTIAL ELECTR .FT. STORIES TYPE CONSTRUCTION
�j ❑1,as owner of the property,or my employees with wages as their sole
C7a compensation,willdothe work and the structure is not intended or offered for
p sale(Sec.7004,Business and Professions Code:The Contractor's License Law
S$ does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RES.UNITS
who doessuch work himseB orthrwgh his own employee,provided that such
improvements are not intended oroffered for sale.U ltowever,thebuiliingor TOTAL: L�0
improvement Lssold within.neyearofcompletiogtheowner-Wflderwill have
tlr,4urden of proving that he did not build or Improve for purpose of sale.). QTY. PLUM RMIT FEE FLOOD ZONE APN
LJ 4 as owner of the property,am exclusively contracting with Bl oed PERMIT ISSUANCE
contractors to commud the project(Sec.7654,Business and Professions Code:
The Contractor's License Law docs not apply m an owner of property who ALTER-DRAIN&VENT-WA
Wilds or improves thereon,and who contracts for such pl.jece with a
ag6t.,veor(e)Ilcensed pursuant to the Comract.rb License Law. FEE SUMMARY
LII am exempt under Sec. B &P C for this reason eAIX FLOWPROTECT.DEVICEOUTSIDE FEES
Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY RFxE N
WORKMAN COMPENSATION DECLARATION FIX�q,PER TRAP SCHOOLTAX Y_ N_
1 hereby affirm that I have a rerti0cate of consent to self-Inaure,or RECEIPT N
:este dW.okers'Courpensation Insurance ora ceNfled copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
35put
00,Iab CJ
C.mcy nv GAS EA.SYSIEM-0ER
Vd(FA) RFGRIPI'N
BUILDING DIVISION FEES
�CertiBed mpybhereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE V
�Certifled copy Vfiled with the tlty lnspectl.n division. �p •3
CERTIFICATE OF IXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAFIITARY-STORM EA 200F7 Date RCCCi t#
(fhi.io,ion need net be completed tithe permit V(.tune hundred dollars
($100)orinssJWATER HFATQO W/VEM/EL[CTR ENERGY FEE Y_ N_
Icertilythat in theperfemsnceofthework forwhich thispermit isnot ed,
1 shall not employ any person In any manner as as to b m bt the
Workeri Compens t woof lifer la.Date WATER SYSI'Elk1/TREATING PAID
O Z Applicant NEW RESIDENTIAL PLMe. SQ.F7. Date RCcei t#
Z NOTICE T0 AP C :IL h rma:ng this Ce Ex Pit y
shwld become subject to the orksn'C.mpenall.n proWions of the habor TOTAL:
P N Code,you at forthwith comply with such provisions or this permit shall be BUILDING . 0
deed revoked.
W > meCONSTRUCTION LENDING AGENCY SEISMIC PEE O
a o Iherebyaffirmthatthembaconstruction lendingagencyfortheperform, TOTAL: ELECTRIC FEE sad
M Z ante of the work for which this permit Is Issued(Sec.3097,Civ.C.) PLUMBING FEE
O O Lender'sName
f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
LL U 1certi(ythal l haveread this application and statethatthe above information
O W exmrred.I dgree to comply with a8 city and county ordinances and gate laws PRRMITI.SSUANCE FEES PAI D:
>. IL relating to building construction,and hereby authonee,representatives of this
f Z city to enter upon the above-mentioned property for Inspection Purpose. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,ydgnmets,cogs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,0(IO CFM) SUBTOTAL: Z
against said City In consequence of the granting of this permit. AICONSTRUCTION TAX
R HANDLING UNIT(OVER CIM(
Signature of Applicant/Contractor Date IXHpUST HOOD(W/DIX:T) COMW NTAX�PAIID:
BAZAR DOES MATERIALS DISCLOS URE {��jf �N��6BL�O
Will the applies fit or future building occupant store or ba nd le harardous HEATING UMT('tt1 t00,000BN) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Ile lth and Safety Code Section 25532(a)? HEATING UNIT(OVER IWM BTU) TOTAL: 2
MYes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE 7 PMO which emit hamnlous so contaminants as defined by the Bay Area Air P8are
ality "go us District? BOILER-COMP GHPOR 100,000 BTU) as
Yea ❑No
have mad the Favrd.us materials requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) �(IM 19Q�
+) the California Health&Safety Code,Sections 25505,25533 and 25534, i s 1117 sot
understand that if the building does not currently have a tenanp that it I,my NEW RESIDENTIAL MECIL SQ.I7.
responsibility to notify the occupant of the requircmenls which at be reel
prior to Issuance of a Certificate of Occupancy. 0 61
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY